R-5401 APPLICATION FOR CITY OF CUPERTINO
NUMBPERMIER R - 5401
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes–I understand that a Class A
roof assembly is required.
NO Irddal I.C.B.O.tl
ADDRESS EXISTING ROOF COVERING -
1
PHONE d )— l d 1 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /
.NAME tl TO BE REMOVED TO BE RETAINED
ADDRESS
F ROOF CARING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed and
Pr fess)provisions o/Chapter a(commencing In with Section WOOD SHAKES
7000)of Division 3 of the Business entl Professions Code,and my license Is In full force and
effect, WOOD SHINGLES
License Class Lie.Number
Date Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contrectofs License Lew(Chapter 0(commencing with Section 7000)of Division 3 of the
' Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).1:
1-] WOOD SHAKES I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES E]Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale.If,however,the building or Improvement
Is so to within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project d(Sec.70 ,Business,and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an operty who butttl orimproves thereon,antl who contracts for such projects
conn econirenseep au other Contract 's License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I am der a ,B&P.C.for thi son
caner WORKER'S CO NSATIONDECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjuryone of the following declaration:
1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Pf A
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this P A I Building
permit Is issued. $eISn11C
❑ have and will themaintainrt Worker's Compensation the workfor Insurance,as rmit Is I by Section 3700 s ���
the Labor Code,for the performance of the work for which this permit le Issued.My Worker's r � C)
,the
Insurance carrier and Policy number are: R C v Total
Carrier Policy No. C)T?Ejr}PoII,TJALJTIi RIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed If the perri is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cell- All roof^shall be inspected prior to dny roofing rViterial being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE e APPLICANT:Workers'
ompIf,sitar making this Certificate of oExemption,,yu must forthwith Applicant understands and will comply with all non point
subject to the Workers'Com enafter provisions C the Labor Code, comply
with such provisions or this permit shalCbe deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information is correct I agree
to comply with all city and county ordinances and state laws relating to building construction,and All to=,I,�0 eclass"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for on-
sp(We) purposes, / "]
(We)agree s save,expenses
and keep harmless the City ai Cupertino against Ilabilltles,of the granting
coats and expenses wMch may in any way accrue against said City In consequence
of the granting of This permit. SIGNATURE OF APPLICANT DTE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFING POLICY FOR THE CITY OF CUPERTNO BLTLDDgG DE?ART:+CENT
PRIOR TO ISSU\,NCE OF PER.NIIT A,-ID INSPECTION PF--SSE-
It to comply Nvi[h U.B.C. standards and manufacnfrers sec's
1. Prior to permit issuance, you must agr
on reroofing.
2. New roof coverings shall not be applied without firs[ obtaining all inspection and =incn aceroval
from the building inspector. A final inspection and approval shall be obtained from the building
inspector whet[the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
1,) P:einscection or tear off approval.
2.) In progress inspection approval.
3.) Final inspection approval.
a.) Operable smoke de!--.or verification
• b.) Spark arrestor installadon
5. If plywocd is installed,a plywood nail inspection is required
6. If any roof is applied without first obtaining an inspection, you w ll be required to remove all ne.v
rnaterial down 10 the sheathing and a building inspector will inspect all sheathing at that time.
WE UNDERSTAND THE ABOVE POLICY ON REROOFING A.ND WILL COMPLY WITH THE
POLICY
EO v1EOWNERS NAME:
ADDRESS;`.
REROOFING COb1PANYNA2yiE:
APPLICA,`+TS SIGNATURE: �
CITY OF CUPERTINO
BUILDING DEPARTNIE`1T
•
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